FORM

Standard: Fall Protection

FALL HAZARD ASSESSMENT

Building & Location: Task:

Occupation: Department:
Evaluation Completed By: Date:
Roofs
Type of Roof  Flat Roof  Low Slope Roof  Contemp. Slope  Steep Slope Roof
(2”/ft Pitch) (2”/ft – 4”/ft) Roof (4”/ft – 9”/ft) (9”/ft or Higher)
Roof Height
Highest Point: Lowest Point:
Method of Access  Stairs  Ship’s Ladder*  Fixed Ladder*  Portable Ladder*
 Other_______________
*Note: Work conducted on ladders is limited to those activities that allow the employee to maintain three
points of contact with the ladder at all times.
Roofing Material  Membrane  Tar  Shingles
 Ballast Type:________________________  No Ballast

Reason For Equipment / Distance To Edge

Accessing The Roof
 Air Handling Unit ___________(ft.)  Drains ___________(ft.)
 Chiller Tower ___________(ft.)  Heater ___________(ft.)
 Repair ___________(ft.)  Seasonal
___________(ft.)
 Other_________ ___________(ft.) Maintenance
Other Identified  Low Light  Trip Hazards  Hidden Drop-offs  Unstable Footing
Hazards
 Slippery Surfaces  Protruding Objects  Pedestrian Traffic  Open Floor Holes
 Floor Openings  Sloping Surfaces  Unstable Surfaces  Skylights
 Moving Parts  High Wind Velocity  Weather Related  Other__________
Engineering  Guard Rail System  6 ft. Boundary Line  15 ft. Minimum  Roof Anchor
Controls or Parapet( 42”or System (Roofing Distance From Edge (Certified)***
Greater) Work Only)* (Marked)**
Description of
Tasks &
Administrative
Controls In Place:
Fall Protection  Class 3 - Full Body  Boatswain’s chair  Web Lanyard  Retractable
Required Harness (Falls Less Than 2 Lifeline System
Feet)
 Safety Nets (Falls  Cable Positioning  Rope Lanyard  Rope Grabs
Less Than 25 Lanyards
Feet)
 Rail System  Shock Absorbers
*6 ft. barrier is only approved by OSHA for roofing activities, **15 ft. markings and/or barriers must be visible at all times, despite snow cover, ***Facilities with certified roof
anchors must maintain copies of the inspection report and certification documents.
Comments:

Supervisor: Date: EHS Officer: Date:

fall_hazard_assessment_form.doc
Revision Date: 8/20/2014 Page 1 of 5
Overhead Equipment & Ceilings

Type of Elevated
Work Area Description of Overhead Equipment___________________________
Working Height (<4ft)
Height:_______________________________
Access to Elevated  Stairs  Ship’s Ladder*  Fixed Ladder*  Portable Ladder*
Work Area  Other____________
 Aerial Lift  Baker Staging  Potable Stairs __
*Note: Work conducted on ladders is limited to those activities that allow the employee to maintain three
points of contact with the ladder at all times.
Aerial Lifts Only If work is conducted while standing on an aerial lift, list the type of aerial lift that ___________________
is used ___
Reason for Accessing  Check all that apply and provide a brief description of the work that will be conducted:
the Space:
Description
 Electrical _____________________________________________________________________________________
Description
 Repair _____________________________________________________________________________________
Description
 Servicing _____________________________________________________________________________________
Description
 Cleaning _____________________________________________________________________________________
Description
 Mechanical _____________________________________________________________________________________
 Other Description
_____________________________________________________________________________________
Other Identified  Low Light  Trip Hazards  Hidden Drop-offs  Unstable Footing
Hazards
 Slippery Surfaces  Protruding Objects  Pedestrian Traffic  Open Floor Holes
 Floor Openings  Sloping Surfaces  Unstable Surfaces  Skylights
 Moving Parts  High Wind Velocity  Weather Related  Other____________
Engineering Controls
 Guard Rail System
 Anchor  Other__________
(Certified)** __
Description of Tasks
& Administrative
Controls In Place:

Fall Protection  Class 3 - Full Body  Boatswain’s chair  Web Lanyard  Retractable Lifeline
Required Harness (Falls Less Than 2 System
Feet)
 Safety Nets (Falls  Cable Positioning  Rope Lanyard  Rope Grabs
Less Than 25 Lanyards
Feet)
 Rail System  Shock Absorbers
**Facilities with certified roof anchors must maintain copies of the inspection report and certification documents.

Comments:

Supervisor: Date: EHS Officer: Date:

fall_hazard_assessment_form.doc
Revision Date: 8/20/2014 Page 2 of 5
Vertical Shaft
Type of Elevated
Work Area Description of Vertical Shaft___________________________
Working Height (<4ft)
Height:_______________________________
Access to Elevated  Stairs  Ship’s Ladder*  Fixed Ladder*  Portable Ladder*
Work Area  Other____________
 Aerial Lift  Baker Staging  Potable Stairs __
*Note: Work conducted on ladders is limited to those activities that allow the employee to maintain three
points of contact with the ladder at all times.
Aerial Lifts Only If work is conducted while standing on an aerial lift, list the type of aerial lift that ___________________
is used ___
Reason for Accessing  Check all that apply and provide a brief description of the work that will be conducted:
the Space:
Description
 Electrical _____________________________________________________________________________________
Description
 Repair _____________________________________________________________________________________
Description
 Servicing _____________________________________________________________________________________
Description
 Cleaning _____________________________________________________________________________________
Description
 Mechanical _____________________________________________________________________________________
 Other Description
_____________________________________________________________________________________
Other Identified  Low Light  Trip Hazards  Hidden Drop-offs  Unstable Footing
Hazards
 Slippery Surfaces  Protruding Objects  Pedestrian Traffic  Open Floor Holes
 Floor Openings  Sloping Surfaces  Unstable Surfaces  Skylights
 Moving Parts  High Wind Velocity  Weather Related  Other____________
Engineering Controls
 Guard Rail System
 Anchor  Other__________
(Certified)** __
Description of Tasks
& Administrative
Controls In Place:

Fall Protection  Class 3 - Full Body  Boatswain’s chair  Web Lanyard  Retractable Lifeline
Required Harness (Falls Less Than 2 System
Feet)
 Safety Nets (Falls  Cable Positioning  Rope Lanyard  Rope Grabs
Less Than 25 Lanyards
Feet)
 Rail System  Shock Absorbers
**Facilities with certified roof anchors must maintain copies of the inspection report and certification documents.

Comments:

Supervisor: Date: EHS Officer: Date:

fall_hazard_assessment_form.doc
Revision Date: 8/20/2014 Page 3 of 5
Elevated Platform
Type of Elevated
Work Area Description of Elevated Platform___________________________
Working Height (<4ft)
Height:_______________________________
Access to Elevated  Stairs  Ship’s Ladder*  Fixed Ladder*  Portable Ladder*
Work Area  Other____________
 Aerial Lift  Baker Staging  Potable Stairs __
*Note: Work conducted on ladders is limited to those activities that allow the employee to maintain three
points of contact with the ladder at all times.
Aerial Lifts Only If work is conducted while standing on an aerial lift, list the type of aerial lift that ___________________
is used ___
Reason for Accessing  Check all that apply and provide a brief description of the work that will be conducted:
the Space:
Description
 Electrical _____________________________________________________________________________________
Description
 Repair _____________________________________________________________________________________
Description
 Servicing _____________________________________________________________________________________
Description
 Cleaning _____________________________________________________________________________________
Description
 Mechanical _____________________________________________________________________________________
 Other Description
_____________________________________________________________________________________
Other Identified  Low Light  Trip Hazards  Hidden Drop-offs  Unstable Footing
Hazards
 Slippery Surfaces  Protruding Objects  Pedestrian Traffic  Open Floor Holes
 Floor Openings  Sloping Surfaces  Unstable Surfaces  Skylights
 Moving Parts  High Wind Velocity  Weather Related  Other____________
Engineering Controls
 Guard Rail System
 Anchor  Other__________
(Certified)** __
Description of Tasks
& Administrative
Controls In Place:

Fall Protection  Class 3 - Full Body  Boatswain’s chair  Web Lanyard  Retractable Lifeline
Required Harness (Falls Less Than 2 System
Feet)
 Safety Nets (Falls  Cable Positioning  Rope Lanyard  Rope Grabs
Less Than 25 Lanyards
Feet)
 Rail System  Shock Absorbers
**Facilities with certified roof anchors must maintain copies of the inspection report and certification documents.

Comments:

Supervisor: Date: EHS Officer: Date:

fall_hazard_assessment_form.doc
Revision Date: 8/20/2014 Page 4 of 5
Open-sided Floor
Type of Elevated
Work Area
Working Height (<4ft)
Access to Elevated
Work Area
Aerial Lifts Only
Reason for Accessing
the Space:
 Electrical
 Repair
 Servicing
 Cleaning
 Mechanical
 Other
Other Identified
Hazards
Engineering Controls
Description of Tasks
& Administrative
Controls In Place:
Description of Opensided Floor___________________________
Height:_______________________________
 Stairs  Ship’s Ladder*  Fixed Ladder*  Portable Ladder*
 Other____________
 Aerial Lift  Baker Staging  Potable Stairs __
*Note: Work conducted on ladders is limited to those activities that allow the employee to maintain three
points of contact with the ladder at all times.
If work is conducted while standing on an aerial lift, list the type of aerial lift that ___________________
is used ___
 Check all that apply and provide a brief description of the work that will be conducted:
Description
_____________________________________________________________________________________
Description
_____________________________________________________________________________________
Description
_____________________________________________________________________________________
Description
_____________________________________________________________________________________
Description
_____________________________________________________________________________________
Description
_____________________________________________________________________________________
 Low Light  Trip Hazards  Hidden Drop-offs  Unstable Footing
 Slippery Surfaces  Protruding Objects  Pedestrian Traffic  Open Floor Holes
 Floor Openings  Sloping Surfaces  Unstable Surfaces  Skylights
 Moving Parts  High Wind Velocity  Weather Related  Other____________
 Guard Rail System
 Anchor  Other__________
(Certified)** __

Fall Protection  Class 3 - Full Body  Boatswain’s chair  Web Lanyard  Retractable Lifeline
Required Harness (Falls Less Than 2 System
Feet)
 Safety Nets (Falls  Cable Positioning  Rope Lanyard  Rope Grabs
Less Than 25 Lanyards
Feet)
 Rail System  Shock Absorbers
**Facilities with certified roof anchors must maintain copies of the inspection report and certification documents.
Comments:

Supervisor: Date: EHS Officer: Date:

fall_hazard_assessment_form.doc
Revision Date: 8/20/2014 Page 5 of 5